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Am"rnt 50
iPermit expires 180 days from
issue date
BL,DK-1.31593t
CEIVE DEXPRESS BUILDING PERMIT APPLICAT
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, NtrA 02664
(508) 398-2231 Ext. 1261
+0 t-[q{ch Rd
T
CONSTRUCTION TDDRISS:
AS SE S SO R' S llT ORr\LATIO,'I" :
Map: tqltZ Parc el
O\-INER
N{\IE '+o (na(:
PRESENT.{DDRESS TEL 4
i[OU',"(flono Ras
:!AILrn-C SS
\\.ORK TO BE PERFOR\IED
(Fire Retardant Certificate attached?)
a{rnov+s*oE- 6FJ--.J-6S-6
TEL. #I
Pool fencine
Ae3
gResidential - Commercial Est. Cost ofConstruction S {6r1a oo
Home Improvement CoItractor Lic. #/7?07d Constructioo supervisor ri". * C-S - O 7a Jld
Workman's Compensation lasurance: (check one)
f I am the homeowner XI am the sole proprietor : I have worker's Compensation Insurance
Insurance Company Name: _\}-orker's Comp. Policy$_
Tetrt Du rrtion
Siding; # of Squares Replacement windows: E- 9-_
Roofing: # of Squares_ ( ) Remove existing* (mar. 2 lal'ers)
_ Old Kings Highway/Historic Dist. ( ) Replacing tike for tike
rThc debris will be disposed ofa!
I declare under penalties of
will bejun cause for denial
Applicanr's Signaore:
Owoers Signature (or attachment)
h
peiu]- lhat the stat€ments herern con
ion olmy lrcense and lbr p
Location ofFacilit-v
tained are tlue and correct
rosecutioo under lvl.G L. C
€. rt.
to the best ofmv knowledge arld belief. I undcrstand that any false answer(s)
h.263, Sccrion l.
Date )-aq-a3
Drte: /r.49 -a 3
Approved By
j kon< e qSg f ohoo go{v1
Building Official (or designee)ElvL,\,lL .ADDR ESS
Zoning District
Historical District: a yes I No
Water Resource Protection District:i Yes -No
Flood Plain Zone: i Yes I No
Within 100 ft. of Wedandsi Yes I No
CONTRACTOR:
NA.\,IE
lvood Stove
Replacement doors: #_
Insulation
Dale
The Commonwedlth of Massachusetts
D ep artme nt oJt I nd ustr ial A ccide nts
I Congress Street, Sutte 100
Boston, MA 02114-2017
t|we.mass.gov/dia
\\:orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PER.NIITTING .{IITHORITY.
Applicant In orma ti on Please Print Legibly
Address: 3 q f0onomo.7 R d
Arc you a[ €mployer? Ch.ck th. appropri.t. bor:
l.! I am a cmployer with
-employees
(full and/or pan-time)..
2.[l am a sole propri.to. or paroe.ship and have no cmploy.es working for me in
any capacity. [No workcrs' comp. insuBncc requircd.]
I an a hooeowner doing al) work mysclf [No work.rs' comp. insurance required.] t
I am a homcowltcr and wil] b. hiring cont.actor5 to qonduct all wo* on my property. ! ]/ill
ensue that a.ll contractors cithcr havc workers' compcosation insuranca or are sole
poprictors with no cmployccs.
I arn a gensral conEactor ard I have hircd thc suuconfaltors listcd oD the attached sheer
Thcsc sub-contractgE have ernployecs and have workcrs' comp. insurancc.l
W. arE a corporalon and its officers hav. cx.rciscd lhcf oght ofexcmption pcr MGL c.
152, $l(4), and we haYe no employees. fNo workers' comp. insuraDce rcquir.d.l
4
5
5
CitylStatelZip:S. V ar mo ufr.r fnu Phone #: 5-0& -6 tr.t -.}6 S6
rAny applicant that checksi Homeowncrs who submit
lconE_actors rhat chcck this
box #l must also fill out the section bclow showing their workars' compensation poliry infoarnatiod
this affidavit indicating thry arc doing a.ll work and thco hilc ousjdc conu-actols must submit a ncw affidavit indicaling such.
box must attachad ar additional shcet showing thc namc of thc sub-contractors and state whcthd or no! lhose cntitics have
employccs. lfth. suLcoDE-actors have employees, thcy must p.ovidc &cir workcrs' comp. poliry oumber
I am an employer thqt is Providing workers' compensation insurancelor my employex. Below is the policy andjob sire
inlornwtion-
Insuraace Company Name
Policy # or Self-ins. Lic. #:Expiration Date
Job Site eddress: t#O tlqfoh Rcl. S"Yavw,o'.ritr fiq Ciry/State/Zip:_
Attach a copy ofthe workers' compensation policy declaration page (showing the poticy nu*b"r "od expiration dxe),
Failure to secure coverage as required under MGL c. 152, $25A is a criminal vioiation punishable by a fine up to S I,5 00.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statemert may be forwarded to the Offrce of hvestigations ofthe DIA for insurance
coverage verification.
I do hereby certify nd.er the pains and.penalties of perjury that the in|ormation provid.ed abow b true and co ecL
Si atule:(<.^_/t a
.s*
Official use only. Do not write in thb arca, to be compteted by city or town ofJiciat.
City or Town: __.- permif/License #
lssuing Authority (circte one):
1. Board of Health 2. Building Department 3. City/Town Cterk
6. Other
,{. Electrical Inspector 5. Plumbing Inspector
Phone #:Contact Person:
Name(Busbesyorgarization4ndiyidual): Joh,^ t<qn<
Type of project (required):
7. ! New construction
8. fi.Remodeling
9. n Demolition
10 x Buildiog addition
I l.E Electical repairs or additions
12. I Plumbing repairs or additions
13 . fl Roof repain
14.I Olher....-.....-..-........--
JOHN E. KANE
39 MONOITTOY RD
SOUTH YAHMOUTH, MA 8664
THE COIIIIONWEALTH OF IiAGSACHUSETTS
Ottlc. d Cooaumar Altdrt & Budn..a RaguLdon
HOXE IUPBOVETENT CONTRACTOR
TYPE: lndlvldualB.Or.Edoi EElrldoo17?0€, O5t2,,t?0,24
JOHN KANE
Unders€cretary
7 t2025
commissioner d* X dA'U-
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